Method and apparatus for forming a self-locking adjustable loop

ABSTRACT

An apparatus can include a first flexible member having first and second ends and a first body extending therebetween, where the first body defines a first passage portion. A second flexible member can have first and second ends and a second body extending therebetween, where the second body defines second and third passage portions. The first end of the first flexible member passes into and through the second passage portion such that the first end extends outside of the second passage portion, and the second end of the first flexible member passes into and through the third passage portion such that the second end extends outside of the third passage portion. The first and second ends of the second flexible member pass into and through the first passage portion to form a self-locking adjustable flexible member construct.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a divisional of U.S. patent application Ser. No.13/288,463 filed on Nov. 3, 2011, which is a continuation-in-part ofU.S. patent application Ser. No. 13/111,564 filed on May 19, 2011, nowU.S. Pat. No. 8,574,235 issued on Nov. 5, 2013, which is acontinuation-in-part of U.S. patent application Ser. No. 12/938,902filed on Nov. 3, 2010, now U.S. Pat. No. 8,597,327 issued on Dec. 3,2013, which is a continuation-in-part of U.S. patent application Ser.No. 12/915,962 filed on Oct. 29, 2010, now U.S. Pat. No. 8,562,647issued on Oct. 22, 2013, which is a continuation-in-part of U.S. patentapplication Ser. No. 12/719,337 filed on Mar. 8, 2010, which is acontinuation-in-part of U.S. patent application Ser. No. 12/489,168filed on Jun. 22, 2009, now U.S. Pat. No. 8,361,113 issued on Jan. 29,2013, which is a continuation-in-part of U.S. patent application Ser.No. 12/474,802 filed on May 29, 2009, now U.S. Pat. No. 8,088,130 issuedon Jan. 3, 2012, which is a continuation-in-part of (a) U.S. patentapplication Ser. No. 12/196,405 filed on Aug. 22, 2008, now U.S. Pat.No. 8,128,658 issued on Mar. 6, 2012; (b) U.S. patent application Ser.No. 12/196,407 filed on Aug. 22, 2008, now U.S. Pat. No. 8,137,382issued on Mar. 20, 2012; (c) U.S. patent application Ser. No. 12/196,410filed on Aug. 22, 2008, now U.S. Pat. No. 8,118,836 issued on Feb. 21,2012; and (d) a continuation-in-part of U.S. patent application Ser. No.11/541,506 filed on Sep. 29, 2006, which is now U.S. Pat. No. 7,601,165issued on Oct. 13, 2009.

This application is a divisional of U.S. patent application Ser. No.13/288,463 filed on Nov. 3, 2011, which is a continuation-in-part ofU.S. patent application Ser. No. 12/570,854 filed on Sep. 30, 2009, nowU.S. Pat. No. 8,303,604 issued on Nov. 6, 2012, which is acontinuation-in-part of U.S. patent application Ser. No. 12/014,399filed on Jan. 15, 2008, which is now U.S. Pat. No. 7,909,851 issued onMar. 22, 2011, which is a continuation-in-part of U.S. patentapplication Ser. No. 11/347,661 filed on Feb. 3, 2006, which is now U.S.Pat. No. 7,749,250 issued on Jul. 6, 2010.

This application is a divisional of U.S. patent application Ser. No.13/288,463 filed on Nov. 3, 2011, which is a continuation-in-part ofU.S. patent application Ser. No. 12/702,067 filed on Feb. 8, 2010, nowU.S. Pat. No. 8,672,968 issued on Mar. 18, 2014, which is a continuationof U.S. patent application Ser. No. 11/541,505 filed on Sep. 29, 2006and is now U.S. Pat. No. 7,658,751 issued on Feb. 9, 2010.

This application is a divisional of U.S. patent application Ser. No.13/288,463 filed on Nov. 3, 2011, which is a continuation-in-part ofU.S. patent application Ser. No. 13/102,182 filed on May 6, 2011, nowU.S. Pat. No. 8,231,654 issued on Jul. 31, 2012, which is a divisionalof U.S. patent application Ser. No. 12/196,398 filed Aug. 22, 2008, nowU.S. Pat. No. 7,959,650 issued on Jun. 14, 2011, which is acontinuation-in-part of U.S. patent application Ser. No. 11/784,821filed Apr. 10, 2007.

The disclosures of all of the above applications are incorporated byreference herein.

FIELD

The present disclosure relates generally to methods and apparatus forforming a self-locking adjustable loop.

BACKGROUND

The statements in this section merely provide background informationrelated to the present disclosure and may not constitute prior art.

Tears caused by trauma or disease in soft tissue, such as cartilage,ligament, or muscle, can be repaired by suturing. Various repairtechniques and devices have been developed for facilitating suturingthat include the use of an intermediate member to facilitate couplingthe suture to the soft tissue and are effective for their intendedpurposes. Nevertheless, there is still a need in the relevant art fortissue repair techniques and associated suture constructs forfacilitating suturing without requiring the use of such intermediatemembers.

SUMMARY

This section provides a general summary of the disclosure, and is not acomprehensive disclosure of its full scope or all of its features.

In one aspect, an apparatus for use in surgical implantation is providedin accordance with the present teachings. The apparatus can include afirst flexible member and a second flexible member. The first flexiblemember can have a first end, a second end and a first body extendingtherebetween, where the first body defines a first passage portion. Thesecond flexible member can have a first end, a second end and a secondbody extending therebetween, where the second body defines second andthird passage portions. The first end of the first flexible memberpasses into and through the second passage portion such that the firstend extends outside of the second passage portion, and the second end ofthe first flexible member passes into and through the third passageportion such that the second end extends outside of the third passageportion. The first and second ends of the second flexible member passinto and through the first passage portion of the first flexible memberto form a self-locking adjustable flexible member construct.

In another aspect, a method of using an adjustable flexible memberconstruct in a surgical procedure is provided in accordance with thepresent teachings. The method can include passing a first end of aself-locking adjustable flexible member construct through soft tissue,where the flexible member construct has an adjustable portion formedfrom first and second flexible members coupled to and selectivelymovable relative to each other. A bore can be formed in a bone and ananchor member coupled to a second opposite end of the flexible memberconstruct can be passed into the bore. Tension can be applied to firstand second ends of the first flexible member extending from the anchormember and through the soft tissue. Tension can be applied to first andsecond ends of the second flexible member slidably extending from theanchor member to reduce a size of the adjustable portion of the flexiblemember construct and draw the soft tissue along and relative to thefirst flexible member toward the anchor member to automatically maintainthe reduced size of the self-locking adjustable flexible memberconstruct under tension.

In yet another aspect, a method of using a flexible member construct ina surgical procedure is provided in accordance with the presentteachings. The method can include passing a self-locking adjustablesuture construct through soft tissue, where the suture construct canhave a first suture defining a first passage portion between first andsecond ends and a second suture defining second and third passageportions between third and fourth ends. The first and second ends canpass through the respective second and third passage portions at a firstend of the suture construct and the third and fourth ends passingthrough the first passage portion at a second opposite end of the sutureconstruct. The suture construct can have an adjustable length portionextending between the first passage portion and the second and thirdpassage portions. The first end of the suture construct being passedthough the soft tissue. A fixed length portion of the second sutureextending between the second and third passage portions can bepositioned over a portion of the soft tissue. A bore can be formed in abone and an anchor member slidably coupled to the first passage portioncan be passed into the bore. Tension can be applied to the first andsecond ends of the first suture extending from the soft tissue. Tensioncan be applied to the third and fourth ends of the second sutureslidably extending from the anchor member while maintaining tension inthe first suture to reduce a size of the adjustable portion and draw thesoft tissue along and relative to the first suture toward the anchormember to automatically maintain the reduced size of the sutureconstruct under tension via the first, second and third passageportions.

Further areas of applicability will become apparent from the descriptionprovided and drawings herein. The description and specific examples inthis summary are intended for purposes of illustration only and are notintended to limit the scope of the present disclosure.

DRAWINGS

The present teachings will become more fully understood from thedetailed description, the appended claims and the following drawings.The drawings are for illustrative purposes only and are not intended tolimit the scope of the present disclosure.

FIG. 1 depicts an exemplary adjustable flexible member construct formedfrom two separate flexible member strands according to the presentteachings;

FIG. 2 depicts an exemplary assembly configuration of the adjustableflexible member construct of FIG. 1 having an exemplary fixation membercoupled thereto according to the present teachings;

FIG. 3 depicts an exemplary technique for securing soft tissue to boneusing the adjustable flexible member construct of FIGS. 1 and 2according to the present teachings;

FIG. 4 depicts an exemplary assembly configuration of the adjustableflexible member construct of FIG. 1 having an exemplary flexible anchorcoupled thereto according to the present teachings;

FIG. 5 depicts an exemplary technique for securing soft tissue to boneusing the adjustable flexible member construct of FIG. 4 according tothe present teachings;

FIG. 6 depicts an exemplary adjustable flexible member construct formedfrom two separate flexible member strands according to the presentteachings;

FIG. 7 depicts an exemplary assembly configuration of the adjustableflexible member construct of FIG. 6 having a pair of exemplary flexibleanchors coupled thereto according to the present teachings;

FIG. 8 depicts an exemplary technique for securing soft tissue to boneusing the adjustable flexible member construct of FIGS. 6 and 7according to the present teachings;

FIG. 9 depicts an exemplary adjustable flexible member construct formedfrom two separate flexible member strands according to the presentteachings;

FIGS. 10-13 depict an exemplary adjustable flexible member construct andan exemplary technique for forming the same according to the presentteachings;

FIG. 14 depicts an exemplary technique for securing soft tissue to boneusing the adjustable flexible member construct of FIG. 13 according tothe present teachings;

FIG. 15 depicts an exemplary adjustable flexible member constructaccording to the present teachings;

FIGS. 16-17 depict enlarged views of portions of the adjustable flexiblemember construct of FIG. 15 according to the present teachings;

FIGS. 18-20 depict an exemplary method of forming a portion of theadjustable flexible member construct of FIG. 15 according to the presentteachings;

FIGS. 21-24 depict an exemplary technique for coupling the adjustableflexible member construct of FIG. 15 to soft tissue according to thepresent teachings; and

FIGS. 25-29 depict an exemplary technique for securing the soft tissueto bone using the adjustable flexible member construct of FIG. 15according to the present teachings.

DETAILED DESCRIPTION

The following description is merely exemplary in nature and is in no wayintended to limit the present disclosure, its application, or uses. Itshould be understood that throughout the drawings, correspondingreference numerals indicate like or corresponding parts and features.While the disclosure generally relates to apparatus and associatedmethods for forming self-locking adjustable loops of flexible memberconstructs that can be used in securing soft tissue to bone, such as arotator cuff or distal bicep, the apparatus and methods of the presentteachings can be used in connection with various other soft tissuefixation methods and/or other procedures where flexible membertensioning and securing of soft tissue is required.

Referring to FIG. 1, an adjustable flexible member construct 10 isprovided according to various aspects of the present teachings. Theadjustable flexible member construct 10 can be fashioned from first andsecond flexible members 14, 18 made of any biocompatible materialincluding, but not limited to, non-resorbable polymers, such aspolyethylene or polyester, resorbable polymers, and various combinationsthereof. In various aspects, the flexible members 14, 18 can include ahollow material or core to allow for appropriate tensioning, as will bediscussed herein. In various aspects, the flexible members 14, 18 can besutures. In such aspects, the sutures can be a hollow or braided ormultiple-filament braided suture structure having a hollow core. Invarious aspects, the sutures can be resorbable. In various aspects, theflexible members 14, 18 can define a substantially tubular hollow shape.

Flexible member 14 can include a body 22 extending between a first end26 and a second end 30, and flexible member 18 can similarly include abody 34 extending between a first end 38 and a second end 42. The bodies22, 34 can include respective formed first and second passage portions48, 52, as also shown in FIGS. 1 and 2. In one exemplary aspect, thebodies 22, 34 can include an exterior surface and an interior surfacedefining an elongated passage between the respective first ends 26, 38and second ends 30, 42. The bodies 22, 34 can define the passageportions 48, 52 as having a larger width than remaining portions of thebodies 22, 34. Alternatively, the passage portions 48, 52 can be formedinitially to have the same width or diameter as the remaining portionsof flexible member bodies 22, 34, later expanding in diameter during theconstruction process, which will be discussed below.

The first passage portion 48 can include first and second apertures 58,62 positioned proximate first and second ends 66, 70 thereof. The secondpassage portion 52 can include third and fourth apertures 74, 78positioned proximate third and fourth ends 82, 86 thereof, as shown inFIG. 1. In various aspects, the apertures 58, 62, 74, 78 can be formedduring a braiding process of flexible members 14, 18 as loose portionsbetween pairs of fibers defining flexible members 14, 18, or can beformed during the construction process. Alternatively, ends of theflexible members 14, 18 can be pushed between individual fibers of thebraided flexible members 14, 18 as will be discussed herein. Theadjustable flexible member construct 10 can include a first end 94 and asecond end 96. In one exemplary configuration, the first end 94 can bedefined by the second end 30 of the first flexible member 14 and thesecond end 96 can be defined by the second end 42 of the second flexiblemember 18, as shown for example in FIGS. 1 and 2.

To form the adjustable flexible member construct 10, first end 26 offlexible member 14 can be passed through second passage portion 52 viathird and fourth apertures 74, 78 such that a portion 102 of flexiblemember 14 following first end 26 extends through passage portion 52, asgenerally shown in FIG. 1. In a similar manner, first end 38 of flexiblemember 18 can be passed through the first passage portion 48 via thefirst and second apertures 58, 62 such that a portion 106 of flexiblemember 18 following first end 38 extends through passage portion 48.This configuration can form an adjustable portion 110 of flexible memberconstruct 10 between passage portions 48, 52, and can form fixedportions 114, 118 extending between respective passage portions 48, 52and second ends 30, 42. In one exemplary aspect, adjustable portion 110can include portions 126, 130 of respective flexible members 14, 18extending between passage portions 48, 52, as shown for example in FIG.1.

With additional reference to FIG. 2, adjustable flexible memberconstruct 10 is shown in an assembly configuration 10A where anexemplary anchor member 140 is slidable coupled to flexible memberconstruct 10. In the exemplary configuration illustrated, anchor member140 is a toggle anchor configured to engage a boney structure and iscoupled about the adjustable portion 110 of flexible member construct10. The anchor member 140 can be, for example, a product sold by BiometSports Medicine, LLC under the name ToggleLoc™. A further discussion ofthe anchor member 140 can be found in U.S. Pat. No. 7,601,165. As canalso be seen in FIG. 2, needles 144 or other suitable soft tissuepiercing members can be coupled to second ends 30, 42 of flexiblemembers 14, 18.

Adjustable flexible member construct 10 can provide an ability to securethe adjustable construct 10 directly to soft tissue, as well as providean ability to reduce a size of only a portion of the adjustableconstruct 10 to thereby reduce an overall length of adjustable construct10. In particular, by using the two separate flexible members 14, 18coupled together via spaced apart passage portions 48, 52 in the mannerdiscussed above, tension can be applied to first ends 26, 38 to reduce alength d of adjustable portion 110 relative to fixed portions 114, 118and generally between passage portions 48, 52. In other words,tensioning first ends 26, 38 can draw the passage portions 48, 52 closerto one another thereby reducing a length of the portions 126, 130 (thatform adjustable portion 110) and thus reduce the overall length ofadjustable flexible member construct 10 without changing a length offixed portions 114, 118.

Operation of the adjustable flexible member construct 10 will now bediscussed in further detail with reference to an exemplary surgicaltechnique shown in FIG. 3 where adjustable flexible member constructassembly 10A is used to attach a distal bicep tendon 150 andcorresponding muscle to a radius bone 154. It should be appreciated,however, that adjustable flexible member construct 10 can be used invarious attachment and/or attachment configurations, other than theexample discussed above, to secure soft tissue to bone or anotherportion of the anatomy.

The needles 144 can be used to secure the fixed portions 114, 118 ofadjustable flexible member construct 10 directly to the distal biceptendon 150 via any suitable method, such as the whip stitch shown inFIG. 3. The construction of adjustable flexible member construct 10provides for being able to secure the second ends 30, 42 that form theends of the fixed portions 114, 118 directly to the soft tissue withoutrequiring an intermediate fixation member to facilitate fixation of theadjustable construct 10 to the soft tissue. Such a configuration canreduce the complexity of the procedure as well as the apparatus used tosecure the soft tissue to the bone. With the fixed portions beingsecured to the distal bicep tendon 150, the needles can be removed, andsecond ends 30, 42 can be coupled together, such as with a knot, asshown in FIG. 3.

The anchor member 140 can be passed through a bore 160 formed throughthe radius bone 154 and secured relative to an outer surface 164 of theradius bone 154 adjacent an opening 168 of bore 160. The first ends 26,38 of flexible members 14, 18 that form adjustable construct 10 can thenbe tensioned to reduce a size of the adjustable portion 110 and draw thedistal bicep tendon 150 into secure engagement with the radius bone 154,as shown in FIG. 3. As will be discussed below, the adjustable flexiblemember construct 10 can maintain the reduced size of the adjustableportion 110 and corresponding tension in the adjustable flexible memberconstruct 10 without the use of a knot, as will be discussed below.

The pulling of first ends 26, 38 can cause movement of flexible memberportions 126, 130 relative to passage portions 48, 52 such that theadjustable portion 110 can be reduced to a desired size and/or placed ina desired tension. Tension in flexible member portions 126, 130 andcorresponding fixed portions 114, 118 can cause the bodies 22, 34defining passage portions 48, 52 to be placed in tension and thereforeconstrict about flexible member portions 102, 106 passed therethrough.This constriction reduces the diameter of passage portions 48, 52, thusforming a mechanical interface between the exterior surfaces of portions102, 106 and an interior surface of passage portions 48, 52. Thisconstriction results in static friction between the interior andexterior surfaces at the mechanical interface, causing the adjustableflexible members 14, 18 to “automatically” lock in the reduced size ordiameter configuration in which tension is maintained without requiringa knot or other additional tying technique to maintain such tension.

With additional reference to FIGS. 4 and 5, adjustable flexible memberconstruct 10 is shown in an assembly configuration 10B where a flexibleanchor 176 is coupled thereto. Flexible anchor 176 can be coupled toadjustable portion 110 in a similar position to anchor member 140, asshown in FIG. 4. Flexible anchor 176 can be an elongate member having asleeve or tubular configuration with first and second ends 180, 184 andan internal passage 190 extending therebetween. The flexible anchor 176can be made of resorbable or non-resorbable materials, including ahollow-core braided suture, sponges and sponge-like materials in solidform, perforated materials, woven/braided from biocompatible materialsor fibers, such as, for example, polymer, polyester, polyethylene,cotton, silk, or other natural or synthetic materials.

The flexible anchor 176 can have any properties that allow it to changeshape. In this regard, the flexible anchor 176 can be, for example,compliant, flexible, foldable, squashable, squeezable, deformable, limp,flaccid, elastic, low-modulus, soft, spongy or perforated, or have anyother characteristic property that allows it to change shape. In someaspects, the flexible anchor 176 can be coated with biological orbiocompatible coatings, and also can be soaked in platelets and otherbiologics, which can be easily absorbed by the flexible anchor 176. Inone exemplary configuration, the flexible anchor 176 can be formed froma strand of No. 5 braided polyester suture. In other words, multiplefibers can be braided together to form a hollow braided flexible memberhaving an internal passage.

As shown for example in FIG. 4, adjustable flexible member construct 10can be passed through a first opening 204 in a wall of the flexibleanchor 176, guided into and along the internal passage 190, and passedout of the internal passage 190 through a second opening 212 in a wallof the flexible anchor 176 to associate flexible anchor 176 withadjustable portion 110. The openings 204, 212 can be positionedintermediately between the first and second ends 180, 184 of theflexible anchor 176 at a distance of, for example, one-quarter lengthfrom ends 180, 184. It will be appreciated that the openings 204, 212can be apertures or voids in the woven fabric of the flexible anchor176, such that the openings 204, 212 do not disrupt or break the weaveof the flexible anchor 176 when made of braided or woven material.Further, portions of the flexible anchor 176 between the first andsecond ends 180, 184 and the corresponding first and second openings204, 212, can define anchoring leg or tail portions 216 that can provideadditional resistance for securing the flexible anchor 176 relative to abone, fastener or implant, as will be discussed in greater detailherein.

In operation, adjustable flexible member construct assembly 10B withflexible anchor 176 can operate in a similar manner as the assemblyconfiguration 10A with anchor member 140 discussed above. In thisregard, it should be appreciated that adjustable flexible memberconstruct assembly 10B could be used in place of adjustable flexiblemember construct assembly 10A to secure the distal bicep tendon 150, aswell as in other soft tissue securing techniques.

For example, and with reference to FIGS. 2 and 4-5, adjustable flexiblemember construct assembly 10B can be used to secure a rotator cuff 224to a humerus bone 228. In the exemplary technique depicted in FIG. 5, abore 234 is formed in the humerus 228 through the cortical bone layer238 and into the cancellous bone layer 242. The flexible anchor 176 canbe positioned in bore 234 and the second ends 30, 42 can be passedthrough rotator cuff 224 via needles 144 or another suitable method atlocations 250A and 250B spaced apart from each other. First end 26 canalso be passed through location 250A along with second end 42 and firstend 38 can be passed through second location 250B along with second end30, as shown in FIG. 5.

The second ends 30, 42 of fixed portions 114, 118 extending throughrotator cuff 224 can then be tied in a knot or secured together inanother suitable manner to form a loop portion 254 over rotator cuff224, as also shown in FIG. 5. Tension can then be applied to first ends26, 38 to reduce a size of adjustable portion 110 and secure rotatorcuff 224 to humerus 228. In applying tension to first ends 26, 38,flexible anchor 176 can be drawn into engagement with cortical bonelayer 238 to set the flexible anchor 176 in an anchoring configurationor mass relative to cortical bone layer 238, as also shown in FIG. 5. Inone exemplary configuration, during setting of flexible anchor 176,portions of the anchor, including tail portions 216, can bunch together,collapse, expand and/or change shape to a second shape, configuration orlocking profile 260 to form an anchoring mass 264.

Anchoring mass 264 can then be set or seated against an inner face ofcortical bone layer 238 surrounding bore 234. In an exemplaryconfiguration, second shape or profile 260 can include a width that isgreater than that of the initially formed bore 234 such that portions offlexible anchor 176 can expand into the cancellous bone layer 242 andextend transversely beyond the width or diameter of bore 234 beneath thecortical bone 238. For example, the anchoring mass 264 can include awidth in a direction perpendicular to a longitudinal axis of bore 234greater than the width of initially formed bore 234. In one exemplaryconfiguration, the flexible anchor 176 can lock against a ledge 268 ofcortical bone layer 238, as also shown in FIG. 5.

Upon seating of the flexible anchor 176, or in combination therewith,tension applied to first ends 26, 38 can draw loop portion 254 againstrotator cuff 224 and thus draw rotator cuff 224 in secure engagementwith humerus 228. As with the other techniques discussed above,adjustable flexible member construct assembly 10B can automatically lockunder tension and/or load without requiring an additional knot tomaintain the tension.

Turning now to FIGS. 6-8, an adjustable flexible member construct 300 isprovided in accordance with the present teachings. With particularreference to FIG. 6, adjustable flexible member construct 300 caninclude a double loop configuration and can be optionally formed usingthe adjustable flexible member construct 10 discussed above. As can beseen in FIG. 6, adjustable flexible member construct 300 can includefirst and second ends 26, 30 of flexible member 14 extending fromopposite ends of passage portion 52 of flexible member 18, and first andsecond ends 38, 42 of flexible member 18 extending from opposite ends ofpassage portion 48 of flexible member 14.

To form adjustable flexible member construct 300, second end 42 offlexible member 18 of adjustable construct 10 can be passed into passageportion 48 via second aperture 62 and out passage portion 48 via firstaperture 58. Similarly, second end 30 of flexible member 14 ofadjustable construct 10 can be passed into passage portion 52 via fourthaperture 78 and out passage portion 52 via third aperture 74 to form thecooperating double self-locking adjustable loop configuration shown inFIG. 6. In the exemplary configuration illustrated, the first and secondends 26, 30 of flexible member 14 pass through passage portion 52 inopposite directions and the first and second ends 38, 42 of flexiblemember 18 pass through passage portion 48 in opposite directions. Thus,the first and second ends 26, 30 extend from respective opposite ends86, 82 of passage portion 52 and the first and second ends 38, 42 extendfrom respective opposite ends 70, 66 of passage portion 48. Thisconfiguration can thus form a first adjustable loop 304 from flexiblemember 14 in cooperation with passage portion 52 of flexible member 18,and a second adjustable loop 308 from flexible member 18 in cooperationwith passage portion 48 of flexible member 14. In other words, twoadjustable portions are formed between passage portions 48, 52, namelythe adjustable portion 110 and another adjustable portion 302. In theexemplary configuration illustrated, when adjustable flexible memberconstruct 300 is placed under tension, the first adjustable loop 304 canself-lock in cooperation with passage portion 52 and the secondadjustable loop 308 can self-lock in cooperation with passage portion48. In one exemplary aspect, the first and second adjustable loops 304,308 can be co-locking adjustable loops of self-locking adjustableflexible member construct 300.

FIG. 7 illustrates adjustable flexible member construct 300 in anassembly configuration 300A where a pair of flexible anchors 176 arecoupled to the respective passage portions 48, 52. It should beappreciated, however, that the pair of flexible anchors 176 couldalternatively be different fixation members and/or could be coupled tofirst portions 312A, 312B of both the first and second loops 304, 308and second portions 316A, 316B of both the loops 304, 308 of adjustableflexible member construct 300.

The longitudinal and parallel placement of the first and second ends 26,30 of flexible member 14 within and through passage portion 52 and thefirst and second ends 38, 42 of flexible member 18 within and throughpassage portion 48 resists the reverse relative movement of the firstand second ends of each of flexible members 14, 18 once flexible memberconstruct 300/300A is tightened. Upon applying tension to the first andsecond ends 26, 30 and the first and second ends 38, 42, adjustableportions 110, 302 can be reduced to a desired size or placed in adesired tension. Tension in the adjustable portions 110, 302 can causethe bodies of the flexible members 14, 18 defining the passage portions48, 52 to be placed in tension and therefore constrict about theportions of flexible members 14, 18 extending therethrough similarly tothe constriction discussed above with respect to adjustable flexiblemember construct 10. This constriction can cause the adjustable flexiblemember construct 300/300A to “automatically” lock in a reduced size orsmaller diameter configuration and maintain the tension withoutrequiring a knot.

With particular reference to FIG. 8, an exemplary technique for couplingsoft tissue to bone with adjustable flexible member construct assembly300A will now be discussed in accordance with the present teachings. Inone exemplary aspect, adjustable flexible member construct assembly 300Acan be used to secure the rotator cuff 224 to the humerus 228. In thisaspect, the flexible anchor 176 coupled to passage portion 52 can bepositioned in a first bore 324 formed in the humerus 228 in a similarmanner as bore 234 discussed above. In the exemplary aspect illustrated,first bore 324 can be formed in humerus 228 adjacent an end 328 ofrotator cuff 224, as shown in FIG. 8. The adjustable construct assembly300A can then be positioned over a portion 334 of the rotator cuff 224and pierced through rotator cuff 224 such that the flexible anchor 176coupled to the second passage portion 48 is positioned within a secondbore 338 spaced apart from the first bore 324. At this point, theadjustable portions 110, 302 can extend from each of the passageportions 48, 52 over the rotator cuff 224, as shown in FIG. 8.

Tension can then be applied to the first and second ends 26, 30 offlexible member 14 and the first and second ends 38, 42 of flexiblemember 18 to reduce a size of the adjustable portions 110, 302 and drawthe rotator cuff 224 into secure engagement with the humerus 228. Asdiscussed above, tensioning the first and second ends 26, 30, 38, 42places the adjustable portions 110, 302 under tension thereby causingthe passage portions 48, 52 to constrict and automatically lock theflexible members 14, 18 in place under the desired tension without theuse of a knot. Further, tensioning the free ends 26, 30, 38, 42 can drawflexible anchors 176 in bores 324, 338 against the cortical bone layer238 such that tail portions 216 engage the ledge 268 of cortical bonelayer 238 thus changing a shape of the flexible anchors 176 from a firstprofile when the flexible anchors 176 are inserted into the bores 324,338 to the second profile 260 shown in FIG. 8 where tail portions engagethe ledge 268 of cortical bone layer 238. In one exemplaryconfiguration, flexible anchors 176 can change from the first shape orprofile to the second shape or profile 260 forming anchoring mass 264against ledge 268, as shown in FIG. 8 with reference to FIG. 5.

It should be appreciated that while the rotator cuff technique has beendiscussed above in connection with placing passage portion 48 in bore338 and passage portion 52 in bore 324, either passage portion 48, 52could be placed in either bore 324, 338. Further, flexible anchors 176coupled to first portions 312A, 312B and second portions 316A, 316Bcould alternatively be positioned in the bores 324, 338. In addition,more than one adjustable flexible member construct assembly 300A couldbe utilized to secure the rotator cuff 224 to humerus 228 using the sameor additional bores formed in humerus 228.

Turning now to FIG. 9, an adjustable flexible member construct 350 isprovided according to the present teachings. The adjustable flexiblemember construct 350 can include a double loop configuration as well astwo passage portions 48, 48A defined by flexible member 14 and twopassage portions 52, 52A defined by flexible member 18. Adjustableflexible member construct 350 can also be formed based on the adjustableflexible member construct 10 discussed above. In this regard, flexiblemember 14 can include the second passage portion 48A and flexible member18 can include the second passage portion 52A. In the exemplaryconfiguration illustrated, each of the second passage portions 48A, 52Aare spaced apart from the corresponding first passage portions 48, 52.Passage portion 48A can include a fifth aperture 354 and a sixthaperture 358, and passage portion 52A can include a seventh aperture 362and an eighth aperture 366.

Using adjustable flexible member construct 10 with the second passageportions 48A, 52A discussed above, second end 30 of flexible member 14can be passed into passage portion 52A via aperture 366 and out viaaperture 362, as shown in FIG. 9. Similarly, second end 42 of flexiblemember 18 can be passed into passage portion 48A via aperture 358 andout via aperture 354. This construction can provide a double loopconfiguration similar to construct 300, but with four passage portions.In this regard, adjustable portion 110 can remain between passageportions 48 and 52, as shown in FIG. 9. However, adjustable portion 302,depicted in FIG. 9 as 302A, can be positioned between second passageportions 48A and 52A. Adjustable flexible member construct 350 canautomatically lock when placed under tension similar to the constructsdiscussed above, and can also be provided in various assemblyconfigurations, such as with flexible anchors 176. In this regard,construct 350 can be used to secure soft tissue to bone, such as in theexemplary rotator cuff technique discussed above, as well as to compresstwo bone portions together, such as discussed in commonly owned,co-pending U.S. Pub. Nos. 2010/0211075 and 2011/0106153, the disclosuresof which are incorporated by reference herein.

With additional reference to FIGS. 10-14, an adjustable flexible memberconstruct 400 is provided in accordance with the present teachings.FIGS. 10-13 illustrate an exemplary method of forming construct 400 andFIG. 14 illustrates an exemplary technique of securing soft tissue tobone using construct 400. The adjustable flexible member construct 400can be fashioned from either a single flexible member, such as flexiblemember 14, or from two flexible members, such as by using adjustableflexible member construct 10 as a starting point.

Forming adjustable flexible member construct 400 from a single flexiblemember, such as flexible member 14, will now be discussed withparticular reference to FIGS. 10-13. In this aspect, the adjustableflexible member construct 400 can include a first end 404, a firstformed passage portion 408, a second end 412, a second formed passageportion 416, and a fixed length loop portion 420 (when formed from asingle flexible member) connecting the first and second passage portions408, 416, as shown in FIG. 10. In the exemplary configurationillustrated, flexible member construct 400 can include an elongated body424 having an exterior surface and an interior surface defining anelongated passage between the first and second ends 404, 412. The body424 can define the first and second passage portions 408, 416 and thefixed length portion 420 therebetween. Passage portions 408, 416 caneach include first apertures 428, 432 positioned proximate one endthereof, and second apertures 436, 440 positioned proximate a secondopposite end thereof. The passage portions 408, 416 can be formed tohave a larger width or diameter than remaining portions of flexiblemember 14, as also shown in FIG. 10. Alternatively, the passage portions408, 416 can be formed initially to have the same width or diameter asthe remaining portions of flexible member 14, later expanding indiameter during the construction process. In various aspects, the firstand second apertures 428, 432, 436, 440 can be formed during a braidingprocess of flexible member 14 as loose portions between pairs of fibersdefining flexible member 14, or can be formed during the constructionprocess. Alternatively, the first and second ends can be pushed betweenindividual fibers of the braided flexible member 14.

The first end 404 can be passed through second passage portion 416 viafirst and second apertures 432, 440, as generally shown in FIGS. 11 and12. In a similar manner, second end 412 can be passed through the firstpassage portion 408 via the first and second apertures 428, 436, as alsoshown in FIGS. 11 and 12. Subsequently, as shown in FIG. 12 withreference to FIG. 10, first end 404 can be passed through the firstpassage portion 408 via second and first apertures 436, 428,respectively. First end 404 can follow a path that is opposite indirection to a path followed by a portion 450 of the flexible member 14that has already passed through first passage portion 408 whilefollowing second end 412 through first and second apertures 428, 436.

Similarly, second end 412 can be passed through the second passageportion 416 via second and first apertures 440, 432, respectively.Second end 412 can follow a path that is opposite in direction to a pathfollowed by a portion 454 of the flexible member 14 that has alreadypassed through second passage portion 416 while following first end 404through first and second apertures 432, 440. This results in portions458, 462 of flexible member 14 being positioned parallel orsubstantially parallel to portions 450, 454 in passage portions 408,416. Passing the first and second ends 404, 412 through passage portions408, 416 as discussed above forms adjustable loops 470, 474, as shown inFIG. 10. The first and second ends 404, 412 can be passed through thesame apertures in each passage portion 408, 416 or, alternatively,through separate apertures in each passage portion 408, 416.

The fixed portion 420 can then be cut, as shown in FIG. 13, toeffectively form two flexible members 14′ and 18′ having fixed lengthportions 114′, 118′ with ends 30′ and 42′. Needles 144 or other flexiblemember passing instruments can be coupled to ends 30′, 42′ and aflexible anchor 176 can be coupled to loops 470, 474 to form theconstruct 400, as illustrated in FIG. 13. Ends 404, 412 can also be tiedin an optional knot 482.

The adjustable flexible member construct 400 can thus provide a doubleadjustable loop configuration via loops 470, 474 while also providingfixed portions 114′, 118′ extending from passage portions 408, 416. Aswill be discussed in greater detail herein, this configuration can beused, for example, to couple soft anchor 176 to loops 470, 474 andcouple fixed length portions 114′, 118′ directly to soft tissue.

In another exemplary aspect, adjustable flexible member construct 400can be formed starting with two separate flexible members, such asflexible members 14, 18. For example, and with reference to FIG. 13 andadjustable flexible member construct assembly 10A discussed above inFIG. 4, first end 26 of flexible member 14 can be passed into passageportion 48 via second aperture 62 and out via first aperture 58 therebypassing through passage portion 48 in an opposite direction as flexiblemember 18. In a similar manner, first end 38 of flexible member 18 canbe passed into passage portion 52 via fourth aperture 78 and out viathird aperture 74 thereby passing through passage portion 52 in anopposite direction as flexible member 14. This technique can thus alsobe used to form adjustable flexible member construct 400 having fixedlength portions 114′, 118′ and two adjustable loops 470, 474 formed byadjustable portions 110 and 302″ extending between passage portions 408,416.

With particular reference to FIGS. 13 and 14, operation of adjustableflexible member construct 400 will now be discussed in greater detail inconnection with an exemplary technique where construct 400 is used toattach soft tissue to bone. In one exemplary aspect, fixed portions114′, 118′ can be coupled to soft tissue, such as the distal biceptendon 150, using needles 144. In one exemplary configuration, fixedportions can be 114′, 118′ can be directly sutured to the soft issue,such as via the whip stitch shown in FIG. 14, and then the remainingfixed portions 114′, 118′ and needle 144 can be removed. The ends 404,412 can be optionally tied together and passed through the bore 160formed in the radius bone 154 along with the a portion of the loops 470,474 such that flexible anchor 176 is positioned through bore 160.

Tension can then be applied to ends 404, 412 to reduce a size of loops470, 474 and/or adjustment portions 110, 302″ and draw the distal biceptendon 150 toward radius bone 154 and into secure engagement therewith.Tensioning ends 404, 412 can place the bicep tendon 150 and associatedmuscle, as well as the flexible members 14′, 18′ of the adjustableconstruct 400 under a desired tension. Similar to the constructsdiscussed above, tension in flexible members 14, 18 can cause thepassage portions 408, 416 to constrict and thereby automatically lockthe adjustment portions 110, 302″ to maintain the desired tensionwithout the use of a knot.

With additional reference to FIGS. 15-29, an adjustable flexible memberconstruct 500 and associated exemplary surgical technique will now bediscussed in accordance with various aspects of the present teachings.As will be discussed in greater detail below, adjustable flexible memberconstruct 500 can be formed from two separate flexible members and canfacilitate coupling a fixed portion of the construct directly to softtissue without requiring an intermediate coupling member.

The adjustable flexible member construct 500 can be fashioned from thefirst and second flexible members 14, 18 and, as will become apparentfrom the discussion below, can include features similar to aspects ofadjustable flexible member construct 300 shown in FIG. 6 and adjustableflexible member construct 350 shown in FIG. 9. In this configuration,the body 22 of first flexible member 14 can define one passage portion48 having first and second apertures 58, 62, as generally shown in FIG.15 and the enlarged view of FIG. 17. Such a configuration of flexiblemember 14 is also shown in FIG. 6, with particular reference to a lefthand side of construct 300. The body 34 of flexible member 18 can definetwo passage portions 52, 52A having respective apertures 74, 78 and 362,366, as generally shown in FIG. 15 with reference to the enlarged viewof FIG. 16. As can be seen, passage portions 52, 52A can be spaced apartfrom each other by a fixed portion 508 of flexible member 18. Such aconfiguration of flexible member 18 is also shown in FIG. 9, withparticular reference to a left hand side of construct 350.

To form adjustable flexible member construct 500, the first end 26 offlexible member 14 can be passed into and through passage portion 52 viaapertures 74, 78 and second end 30 can be passed into and throughpassage portion 52A via apertures 366, 362. The first end 38 of flexiblemember 18 can be passed into and through passage portion 48 viaapertures 58, 62, and the second end 42 can be passed through passageportion 48 in an opposite direction as first end 38 via apertures 62,58. It should be appreciated that first and second ends 38, 42 can bepassed through passage portion 48 via the same or different apertures.

First and second ends 38, 42 can then optionally be tied in a knot 510or otherwise coupled together, as shown in FIG. 15. In the exemplaryconfiguration illustrated in FIGS. 15-29, adjustable flexible memberconstruct 500 can include needle 144 slidably coupled to the fixedportion 508 at a first end 512 of construct 500, and anchor member 140coupled to passage portion 48 via aperture 516 at a second opposite end520 of construct 500. In this exemplary configuration, passage portion48, as well as first and second ends 38, 42 of flexible member 18extending therethrough are slidably positioned through aperture 516 ofanchor member 140, as shown in FIG. 17. While adjustable flexible memberconstruct 500 is shown and discussed in connection with needle 144 andanchor member 140, it should be appreciated that construct 500 can beused with or without needle 144 and anchor member 140 and/or with othersuitable suture passing members and/or fixation members, such asflexible anchor 176.

This configuration of adjustable flexible member construct 500 can formfirst and second adjustment portions 522, 526 extending between passageportions 52, 52A of flexible member 18 and passage portion 48 offlexible member 14, as shown in FIG. 15. Further, the loopedconfiguration of flexible member 18 in cooperation with passage portions48, 52, 52A can also provide an adjustable loop 532. As will bediscussed in greater detail below, tension can be applied to ends 26, 30of flexible member 14 and ends 38, 42 of flexible member 18 to reduce asize of loop 532 and adjustment portions 522, 526. In this regard,adjustable flexible member construct 500 can be used to attach softtissue to bone and automatically lock the suture construct 500 viapassage portions 48, 52 and 52A at a desired size or tensile loadwithout the use of a knot.

To facilitate coupling the first end 512 of adjustable flexible memberconstruct 500 to soft tissue, free ends 26, 30 at the first end 512 canbe optionally passed or tucked inside body 22 and can form a loopportion 538, as shown in FIG. 18. Any remaining portions of ends 26, 30extending from body 22 can then be trimmed, as shown in FIG. 19. Beforetucking the free ends 26, 30 into body 22, one of the free end 26 or 30can be passed inside the coupling loop 542 such that needle 144 can thenbe passed around both fixed portion 508 and formed loop portion 538, asalso shown in FIG. 19. A size of loop 532 can be optionally adjustedrelative to passage portion 48 to substantially align fixed portion 508with formed loop portion 538, as shown in FIG. 20. Having the fixedportion 508 align with formed loop portion 538 can facilitate easierpassing of construct 500 through soft tissue, as will be discussedbelow.

With particular reference to FIGS. 21-24, coupling adjustable flexiblemember construct 500 to soft tissue will now be discussed in greaterdetail. In the exemplary configuration illustrated, construct 500 isshown being coupled to distal bicep tendon 150. It should beappreciated, however, that construct 500 can be used in varioustechniques for coupling soft tissue to bone, such as in an ACLconstruction procedure, for example. Needle 144 can be used to passfirst end 512 of construct 500 through distal bicep tendon 150 a firsttime, as shown in FIG. 21. The second end 520 of construct 500 alongwith an end 552 of distal bicep tendon 150 can be passed through aportion 554 of construct 500 extending between the first end 512 and anexit side 558 of distal bicep tendon 150 opposite an entrance side 562.Needle 144 along with first end 512 can then be passed through theentrance side 562 again and the process repeated to form a weave-likepattern 568 shown in FIG. 23. The needle 144 can then be removed fromfirst end 512, as shown in FIG. 24. The pattern 568 can form anon-tortuous path for the suture so as to facilitate initial sliding ofthe distal bicep tendon 150 relative to flexible member 14, as will bediscussed below.

With additional reference to FIGS. 25-29, attaching the distal biceptendon 150 to the radius bone 154 will now be discussed in greaterdetail. With particular reference to FIGS. 25 and 26, the second end 520of construct 500 can be passed through bore 160 in radius bone 154. Theformed loop portion 538 can be separated from alignment with the fixedportion 508, as shown in FIG. 25, and tension can be applied to theconstruct 500 via ends 26, 30 and ends 38, 42. In the exemplaryconfiguration illustrated in FIG. 26, ends 26, 30 (FIG. 20) are in theform of optional loop 538 and ends 38, 42 are in the form of an optionalloop 576 via knot 510. In this configuration, the loops 538 and 576 canbe tensioned either by hand or with any appropriate instrument. Applyingtension to construct 500 in this manner can seat anchor member 140against outer surface 164 of radius bone 154 and facilitate drawingdistal bicep tendon 150 toward and into secure engagement with radiusbone 154, as will be discussed below.

In particular, once anchor member 140 is seated against radius bone 154with an initial amount of tension being applied to construct 500 toremove any slack from the construct, further tensioning of the flexiblemember 18 via loop 576 can draw fixed portion 508 against the distalbicep tendon 150 by moving the flexible member 18 relative to theflexible member 14 and the distal bicep tendon 150. In other words,flexible member 14, under tension, remains taut relative to anchormember 140 such that flexible member 14 can initially serve a functionof a guidewire or guiding path for moving distal bicep tendon 150 towardradius bone 154. Further tension applied to loop 576 of flexible member18 can shorten a length of loop 532 relative to passage portion 48 andthus draw distal bicep tendon 150 along flexible member 14 toward radiusbone 154, as shown in FIGS. 27 and 28.

The adjustable flexible member construct 500 can provide support forholding the distal bicep tendon 150 and associated muscle to the radiusbone 154 via the four flexible member strands extending between thepassage portion 48 and the passage portions 52, 52A. In particular,although the flexible member 14 serves the initial function of aguidewire while drawing the distal bicep tendon 150 toward the radiusbone 154, it also serves to hold the distal bicep tendon 150 at thedesire tension/load via the portions of flexible member 18 that form theadjustment portions that extend between passage portion 48 at the anchormember 140 and passage portions 52, 52A at the distal bicep tendon 150.Similarly, the portions of flexible member 18 that form part ofadjustment portions 522, 526 extending between the passage portions 52,52A and passage portion 48 can also hold the bicep tendon 150 at thedesired tension. In a similar manner to the constructs discussed above,the passage portions 48, 52, 52A can automatically lock the respectiveflexible members 18, 14 under the desired tension/load without the useof a knot.

Upon tensioning flexible member 18 via loop 576 a sufficient amount todraw distal bicep tendon 150 into secure engagement with radius bone 154under a desired tensile load, such as shown in FIG. 29, the ends 26, 30of flexible member 14 extending from passage portions 52, 52A can betrimmed. The ends 38, 42 extending from passage portion 48 and bore 160in radius bone 154 can also be trimmed.

While one or more specific examples have been described and illustrated,it will be understood by those skilled in the art that various changesmay be made and equivalence may be substituted for elements thereofwithout departing from the scope of the present teachings as defined inthe claims. Furthermore, the mixing and matching of features, elementsand/or functions between various examples may be expressly contemplatedherein so that one skilled in the art would appreciate from the presentteachings that features, elements and/or functions of one example may beincorporated into another example as appropriate, unless describedotherwise above. Moreover, many modifications may be made to adapt aparticular situation or material to the present teachings withoutdeparting from the essential scope thereof.

What is claimed is:
 1. An apparatus for use in surgical implantation,comprising: a first flexible member having a first end, a second end anda first body extending between the first end and the second end of thefirst flexible member, the first body defining a first longitudinalpassage portion in the first flexible member; and a second flexiblemember having a first end, a second end and a second body extendingbetween the first end and the second end of the second flexible member,the second body defining a second longitudinal passage portion and athird longitudinal passage portion in the second flexible member,wherein the first flexible member and the second flexible member areformed as separate members but within the apparatus are coupled togetherto form a self-locking adjustable flexible member construct whichincludes: (i) the first end of the first flexible member passing intoand through the second longitudinal passage portion such that the firstend of the first flexible member extends outside of the secondlongitudinal passage portion, (ii) the second end of the first flexiblemember passing into and through the third longitudinal passage portionsuch that the second end of the first flexible member extends outside ofthe third longitudinal passage portion, (iii) the first end of thesecond flexible member passing into and through the first longitudinalpassage portion such that the first end of the second flexible memberextends outside the first longitudinal passage portion; and (iv) thesecond end of the second flexible member passing into and through thefirst longitudinal passage portion such that the second end of thesecond flexible member extends outside the first longitudinal passageportion.
 2. The apparatus of claim 1, wherein the first and second endsof the second flexible member extend into and through the firstlongitudinal passage portion in opposite directions such that the firstend of the second flexible member extends from one end of the firstlongitudinal passage portion and the second end of the second flexiblemember extends from the other opposite end of the first longitudinalpassage portion.
 3. The apparatus of claim 1, further comprising thesecond and third longitudinal passage portions spaced apart from eachother by a fixed length portion of the body of the second flexiblemember.
 4. The apparatus of claim 3, wherein the fixed length portion ofthe second flexible member in cooperation with the first and second endsof the second flexible member passing through the first longitudinalpassage portion forms a self-locking adjustable loop.
 5. The apparatusof claim 3, further comprising a first adjustable length portion formedby first portions of the first and second flexible members extendingbetween the first and second longitudinal passage portions, and a secondadjustable length portion formed by separate second portions of thefirst and second flexible members extending between the first and thirdlongitudinal passage portions; wherein applying tension to the first andsecond ends of the first and second flexible members reduces a size ofthe first and second adjustable length portions.
 6. The apparatus ofclaim 5, wherein the adjustable flexible member construct is configuredto automatically lock under tension to maintain the reduced size of thefirst and second adjustable length portions under tension in an absenceof a knot.
 7. The apparatus of claim 5, wherein the first body defines ahollow interior, wherein the first end of the first flexible memberpasses into the hollow interior of the first body proximate the secondend of the first flexible member, and wherein the second end of thefirst flexible member passes into the hollow interior of the first bodyproximate the first end of the first flexible member to form a loopportion extending from an opposite side of the second and thirdlongitudinal passage portions as the first and second adjustable lengthportions.
 8. The apparatus of claim 7, further comprising a needlemember removably coupled to the fixed length portion and the loopportion, the needle member adapted to facilitate passing the adjustableflexible member construct through tissue.
 9. The apparatus of claim 3,further comprising an anchor member slidably coupled to the firstlongitudinal passage portion.
 10. The apparatus of claim 9, wherein theanchor member comprises an aperture, the first longitudinal passageportion extending through the aperture such that the first and secondends of the second flexible member are adjustable relative to the anchormember.
 11. The apparatus of claim 1, wherein the first and secondflexible members comprise a suture formed of a braided or wovenstructure.
 12. The apparatus of claim 1, wherein the first flexiblemember is a unitary member formed from a single piece of braided suturesuch that the first end, the second end and the first body of the firstflexible member all form part of the unitary member.
 13. The apparatusof claim 12, wherein the second flexible member is a second unitarymember formed from another single piece of braided suture such that thefirst end, the second end and the second body of the second flexiblemember all form part of the second unitary member.
 14. An apparatus foruse in surgical implantation, comprising: a first flexible member havinga first end, a second end, and a first body extending between the firstend and the second end of the first flexible member, the first bodydefining a first longitudinal passage portion in the first flexiblemember; and a second flexible member having a first end, a second end,and a second body extending between the first end and the second end ofthe second flexible member, the second body defining a secondlongitudinal passage portion in the second flexible member, wherein thefirst flexible member and the second flexible member are formed asseparate members but within the apparatus are coupled together to form aself-locking adjustable flexible member construct which includes thefirst end of the first flexible member passing into and through thesecond longitudinal passage portion and the first end of the secondflexible member passing into and through the first longitudinal passageportion to form an adjustable portion between the first longitudinalpassage portion and the second longitudinal passage portion.
 15. Theapparatus of claim 14, further comprising a first fixed length portionof the first flexible member extending between the first longitudinalpassage portion and the second end of the first flexible member and asecond fixed length portion of the second flexible member extendingbetween the second longitudinal passage portion and the second end ofthe second flexible member.
 16. The apparatus of claim 15, furthercomprising an anchor positioned on the adjustable portion.
 17. Theapparatus of claim 16, wherein the anchor is one of either a rigidanchor or a flexible anchor.
 18. The apparatus of claim 16, wherein theanchor is a flexible anchor having first and second ends and an internalpassage extending therebetween where the adjustable portion passesthrough first and second openings in a wall of the flexible anchorbetween the first and second ends of the flexible anchor to define firstand second tail portions of the anchor.
 19. The apparatus of claim 14,wherein the second end of the first flexible member passes into andthrough the second longitudinal passage portion and the second end ofthe second flexible member passes into and through the firstlongitudinal passage portion and the adjustable portion is defined bytwo adjustable loops.
 20. The apparatus of claim 19, further comprisinga first anchor coupled to the first longitudinal passage portion and asecond anchor coupled to the second longitudinal passage portion. 21.The apparatus of claim 14, wherein the first flexible member defines athird longitudinal passage portion and the second flexible memberdefines a fourth longitudinal passage portion, the second end of thefirst flexible member passing into and through the fourth longitudinalpassage portion and the second end of the second flexible member passinginto and through the third longitudinal passage portion.
 22. Anapparatus for use in surgical implantation, comprising: a first flexiblemember having a first end, a second end, and a first body extendingbetween the first end and the second end of the first flexible member,the first body defining a first longitudinal passage portion in thefirst flexible member; a second flexible member having a first end, asecond end, and a second body extending between the first end and thesecond end of the second flexible member, the second body defining asecond longitudinal passage portion in the second flexible member,wherein the first flexible member and the second flexible member areformed as separate members, and wherein within the apparatus the firstflexible member is coupled to the second flexible member by passing intoand through the second longitudinal passage portion and the secondflexible member is coupled to the first flexible member by passing intoand through the first longitudinal passage portion; and an anchorcoupled to the first and second flexible members.